Male Genitourinary System

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Transcript of Male Genitourinary System

Genitourinary System Health Assessment of the Male PatientAssessmentPenis Glans Corona Urethra Foreskin FrenulumScrotum Rugae Cremaster Muscle Testes Epididymis vas deferens Spermaticc cord ejaculatory duct lymphaticsInguinal Area (groin) Inguinal ligamentinguinal canalfemoral canalDevelopmentAnatomySubjectiveObjectiveTalking with patientsQuestions about sexual activityCommunicates acceptancePrompts interest and possibly relief that you introduced the topic.Inguinal area or groin (cont.)Inguinal canal is 4 to 6 cm long in adultOpenings are:Internal ring: 1 to 2 cm above midpoint of inguinal ligamentExternal ring: above and lateral to pubisFemoral canal is inferior to inguinal ligamentPotential space located 3 cm medial to and parallel with femoral arteryYou can use artery as landmark to find this spaceStructure and FunctionInguinal area or groinJuncture of lower abdominal wall and thighKnowledge of these anatomic areas is useful because they are potential sites for a hernia, which is a loop of bowel protruding through a weak spot in musculatureBorders are the anterior superior iliac spine and symphysis pubisBetween these landmarks lies inguinal ligamentInguinal canal lies superior to ligament formed by narrow tunnel passing obliquely between layers of abdominal muscleStructure and FunctionLymphatics of penis and scrotal surface drain into inguinal lymph nodesLymphatics of testes drain into abdomenAbdominal lymph nodes are not accessible to clinical examinationStructure and FunctionSpermatic cord Ascends along posterior border of testis and runs through tunnel of inguinal canal into abdomenHere, vas deferens continues back and down behind bladder, where it joins duct of seminal vesicle to form ejaculatory duct, which empties into urethraStructure and FunctionSpermTransported along series of ductsEpididymis: markedly coiled duct system and main storage site of sperm; comma-shaped structure, curved over top and posterior surface of testisVas deferens: a muscular duct continuous with lower part of epididymis and with other vessels (arteries and veins, lymphatics, nerves) that forms spermatic cordStructure and FunctionTestesHave a solid oval shape, suspended vertically by spermatic cordLeft testis is lower because left spermatic cord is longerTunica vaginalis: double-layered membrane covers each testis and separates it from scrotal wallLayers are lubricated by fluid so that testis can slide within scrotum which helps prevent injuryStructure and FunctionScrotum Cremaster muscle controls size of scrotum by responding to ambient temperatureKeep testes at 3° C below abdominal temperature; best temperature for producing spermWhen it is cold, muscle contracts, raising sac bringing testes closer to body to absorb heat for sperm viabilityAs a result, scrotal skin looks corrugatedWhen it is warmer, the muscle relaxes, scrotum lowers, and skin looks smootherSeptum inside separates sac into halves; in each is a testis, which produces spermStructure and FunctionScrotumScrotumLoose protective sac; continuation of abdominal wallAfter adolescence, scrotal skin deeply pigmented and has large sebaceous folliclesScrotal wall consists of thin skin lying in folds, or rugae, and underlying cremaster muscleStructure and FunctionPenisGlans: at distal end of shaft corpus spongiosum expands into cone of erectile tissueCorona: shoulder where glans joins shaftUrethra transverses corpus spongiosum, and its meatus forms slit at tip of glansForeskin or prepuce forms hood or flap over glansOften removed shortly after birth by circumcisionFrenulum: fold of foreskin extending from urethral meatus ventrallyStructure and FunctionPenisPenisComposed of three cylindrical columns of erectile tissue:Two corpora cavernosa on dorsal sideCorpus spongiosum ventrallyStructure and FunctionMale genital structures include: ExternalPenis and scrotumInternalTestis, epididymis, and vas deferens Glandular structures accessory to genital organs:Prostate, seminal vesicles, and bulbourethral glandsMale Genitourinary SystemInguinal AreaRenal calculiAcute urinary retentionUrethral strictureAbnormal Findings:Urinary ProblemsCarcinomaBegins as red, raised warty growth or as an ulcer, with watery dischargeAs it grows, may necrose and sloughUsually painless; almost always on glans or inner lip of foreskin and following chronic inflammation; enlarged lymph nodes are commonGenital warts, human papillomavirus (HPV)Syphilitic chancreGenital herpes, HSV-2 infectionAbnormal Findings:Male Genital LesionsUnderstanding prostate changes PSA made by normal prostate glandWhen prostate cancer develops, PSA levels increaseBut, benign or noncancerous enlargement of prostate (BPH), age, and prostatitis can cause PSA to increaseThe DRE involves a gloved, lubricated finger being inserted into rectumProstate gland located just in from opening of rectum making it possible to palpate surface of gland manually for bumps or hard areas that may be a developing cancerLess effective than PSA blood test in finding prostate cancer, but it can sometimes find cancers in men who have normal PSA levels; thus both PSA and DRE are recommendedPromoting a Healthy Lifestyle: Screening for Prostate CancerUnderstanding prostate changes Prostate cancer typically detected by testing blood for prostate-specific antigen (PSA) and/or on digital rectal examination (DRE)Recommended that both PSA and DRE should be offered to men yearly, beginning at age 50Men at higher risk for developing prostate cancer, such as African Americans and/or men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than 65) should be offered testing earlierPromoting a Healthy Lifestyle: Screening for Prostate CancerUnderstanding prostate changesDiscussion of prostate health and examination of prostate gland is a unique aspect of male health assessmentGradual enlargement of prostate gland considered to be normal part of agingEnlargement termed benign prostatic hypertrophy, or BPH; it does not raise an individual’s risk for prostate cancer, yet symptoms for BPH and prostate cancer can be very similarPromoting a Healthy Lifestyle: Screening for Prostate CancerDirect inguinal herniaDirectly behind and through external inguinal ring, above inguinal ligament; rarely enters scrotumUsually painless; round swelling close to pubis in area of internal inguinal ring; easily reduced when supineLess common, occurs most often in men over 40 age, rare in womenAcquired weakness; brought on by heavy lifting, muscle atrophy, obesity, chronic cough, or ascitesAbnormal Findings:Inguinal and Femoral Hernias (cont.)Indirect inguinal herniaSac herniates through internal inguinal ring; can remain in canal or pass into scrotumPain with straining; soft swelling that increases with increased intraabdominal pressure; may decrease when lying downMost common; 60% of all hernias; more common in infants less than 1 year old and in males 16 to 20 years oldCongenital or acquiredAbnormal Findings:Inguinal and Femoral HerniasUrethritis, urethral discharge, and dysuriaInfection of urethra, painful burning urinationMeatus edges are reddened, everted, and swollen; purulent urethral discharge is present; urine cloudy with discharge and mucous shredsCause determined by cultureGonococcal urethritis has thick, profuse, yellow or gray-brown dischargeNonspecific urethritis (NSU) may have similar discharge but often has scanty, mucoid discharge About 50% are caused by chlamydia infectionImportant to differentiate as antibiotic treatment differsAbnormal Findings:Male Genital LesionsFemoral herniaPain may be severe, may become strangulatedLeast common, 4% of all hernias; but more common in womenAcquired; due to increased abdominal pressure, muscle weakness, or frequent stoopingAbnormal Findings:Inguinal and Femoral Hernias (cont.)a. Phimosisb. Hypospadiasc. Epispadiasd. Peyronie’s diseasePriapismAbnormal Findings:Abnormalities of the PenisA. Absent testis, cryptorchidismB. Small testis

C. Scrotal herniaD. OrchitisE.Scrotal edemaAbnormal Findings: Abnormalities in the ScrotumSlide 3A. Often young men your age…B. I worry that you might…C. Do you…D. You don’t…do you?2. The nurse is obtaining a sexual history from an adolescent male. Which of the following would be the best way to begin the sexual history interview?Slide 2A. “I will check my testicles for lumps in the shower.”B. “I will bear down and check my groin area while seated.”C. “I will check my testicles while lying on my right side.”D. “I will have my testicles examined by my health care provider every year.”1. The nurse is reviewing the importance of testicular self-examination (TSE) with a 17-year-old male. Which statement by the patient confirms the patient’s understanding of TSE?Audience Response System QuestionsChapter 24: Male Genitourinary SystemJarvis: Physical Examination & Health Assessment, 6th EditionAging menIn older male, you may note thinner, graying pubic hair and decreased size of penisSize of testes may be decreased and may feel less firmScrotal sac pendulous with less rugaeScrotal skin may become excoriated if man continually sits on itObjective Data:Developmental CompetenceInfant or toddler (cont.)Inspect penis and scrotum (cont.)If a hernia is suspected, palpate inguinal areaUse your little finger to reach external inguinal ringObjective Data:Developmental CompetenceInfant or toddler (cont.)Inspect penis and scrotum (cont.)Common scrotal finding in boy under 2 is a hydrocele, or fluid in scrotum; appears as a large scrotum and transilluminates as faint pink glowUsually disappears spontaneouslyInspect inguinal area for a bulgeIf parent gives a positive history of one, try to elicit it by increasing intraabdominal pressureAsk boy to hold his breath and strain down or have him blow up a balloonObjective Data:Developmental CompetenceInfant or toddler (cont.)Inspect penis and scrotum (cont.)Normally, testes are descended and are equal in size bilaterallyImportant to document that you have palpated testes Once palpated, they are considered descended, even if they have retracted momentarily at next visitIf scrotal half feels empty, search for testes along inguinal canal and try to milk them downAsk toddler or child to squat with knees flexed up; this pressure may force the testes down; or have child sit cross-legged to relax reflexObjective Data:Developmental CompetenceInfant or toddler (cont.)Inspect penis and scrotum (cont.)Scrotum size varies with ambient temperature, but overall, infant’s scrotum looks large in relation to penis No bulges, either constant or intermittent, are presentPalpate scrotum and testesCremasteric reflex is strong in infant, pulling testes up into inguinal canal and abdomen from exposure to cold, touch, exercise, or emotion; take care not to elicit reflexKeep your hands warm and palpate from external inguinal ring downBlock inguinal canals with thumb and forefinger of your other hand to prevent testes from retractingObjective Data:Developmental CompetenceInfant or toddler (cont.)Inspect penis and scrotumPenis size usually small in infants and in young boys until pubertyIn obese boy, penis looks even smaller because of folds of skin covering baseIn circumcised infant, glans looks smooth with meatus centered at tipWhile child wears diapers, meatus may be ulcerated from ammonia irritation; more common in circumcised infantsIf possible, observe newborn’s first voiding to assess strength and direction of streamObjective Data:Developmental CompetenceSelf-care: TSE (cont.)Phrase your teaching something like this:A good time to examine testicles is during shower or bath, when your hands are warm and soapy and scrotum is warm; cold hands retract scrotal contentsProcedure is simple; hold scrotum in palm of your hand and gently feel testicles using thumb and first two fingersTesticle is egg-shaped and movable; it feels rubbery with a smooth surfaceAbnormal lumps are very rare and usually not worrisome, but if you ever notice a firm, painless lump, a hard area, or an overall enlarged testicle, call your physician for further checkObjective DataSelf-care: TSE (cont.)Early detection of cancer enhanced if male is familiar with his normal consistencyPoints to include during health teaching are:T - timing, once a monthS - shower, warm water relaxes scrotal sacE - examine, check for and report changes immediatelyObjective DataSelf-care: testicular self-examination (TSE)Encourage self-care by teaching every male from 13 to 14 years old through adulthood how to examine his own testiclesOverall incidence of testicular cancer is still rare, but testicular cancer most commonly occurs in young men age 15 to 40 Males with undescended testicles are at greatest risk, and white males are four times more likely to contract testicular cancer than nonwhitesThis tumor has no early symptoms; if detected early by palpation and treated, cure rate is almost 100%Objective DataInspect and palpate for herniaInspect and palpate for herniaPalpate femoral area for a bulgeNormally you feel noneObjective DataInspect and palpate for herniaInspect inguinal region for bulge as person stands and strains down; normally none is presentPalpate inguinal canalFor right side, ask male to shift his weight onto left legPlace your right index finger low on right scrotal half Palpate up length of spermatic cord, invaginating scrotal skin as you go, to the external inguinal ringIt feels like a triangular slitlike opening, if it will admit your finger, gently insert it into canal and ask person to “bear down;” normally you feel no changeRepeat procedure on the left sideObjective DataInspect and palpate scrotum (cont.)Normally, no other scrotal contents are present; if you find a mass, note:Is there any tenderness?Is the mass distal or proximal to testis?Can you place your fingers over it?Does it reduce when person lies down?Can you auscultate bowel sounds over it?TransilluminationPerform this maneuver only if you note swelling or mass Darken room; shine flashlight from behind scrotal contentsNormal scrotal contents do not transilluminateObjective DataInspect and palpate scrotum (cont.)Palpate gently each scrotal half between your thumb and first two fingersScrotal contents should slide easily; testes normally feel oval, firm and rubbery, smooth, and equal bilaterally, and are freely movable and tender to moderate pressureEach epididymis normally feels discrete, softer than testis, smooth, and nontenderPalpate each spermatic cord between your thumb and forefinger, along its length from epididymis up to external inguinal ringYou should feel a smooth, nontender cordObjective DataInspect and palpate scrotumInspect scrotum as male holds penis out of the way; alternatively, you hold penis out of the way with back of your handScrotal size varies with ambient room temperature; asymmetry is normal, with left scrotal half usually lower than rightSpread rugae out between your fingers; lift sac to inspect posterior surface; normally, no scrotal lesions are present, except commonly found sebaceous cysts; these are yellowish, 1-cm nodules that are firm, nontender, and often multipleObjective DataInspect and palpate penis (cont.)Compress glans anteroposteriorly between your thumb and forefinger; meatus edge should appear pink, smooth, and without dischargeIf you note urethral discharge, collect smear for microscopic examination and cultureIf no discharge shows but person gives history of it, ask him to milk shaft of penis; this should produce a drop of dischargePalpate shaft of penis between your thumb and first two fingersNormally, penis feels smooth, semifirm, and nontenderObjective DataInspect and palpate penisSkin normally looks wrinkled, hairless, and without lesions; dorsal vein may be apparentGlans looks smooth and without lesions; ask uncircumcised male to retract foreskin, or you retract it; it should move easilySome cheesy smegma may have collected under foreskin; after inspection, slide foreskin back to original positionUrethral meatus positioned just about centrallyObjective Data

Your demeanor should be confident and relaxedDo not discuss genitourinary history or sexual practices while you are performing examination as it may be perceived as judgmentalUse a firm deliberate touch, not soft, stroking one If erection does occur, do not stop the examination or leave the room; this only focuses more attention on the erection and increases embarrassmentReassure the male that this is only a normal physiologic response to touchProceed with the rest of examinationObjective DataConcerns are similar to those experienced by female during examination of genitaliaModesty, fear of pain, cold hands, negative judgment, or memory of previously uncomfortable examinationsAdditionally, he may fear comparison to others, or fear having an erection during examination that would be misinterpreted by examinerApprehension becomes manifested in different behaviorsMany act resigned or embarrassed and may avoid eye contactOccasional man will laugh and make jokes to cover embarrassment; also man may refuse examination by female and may insist on male examinerObjective DataEquipment neededGloves: wear gloves during every male genitalia examinationOccasionally may require glass slide for urethral specimenMaterials for cytologyFlashlightObjective DataPreparationPosition male standing with underwear down and appropriate drapingExaminer should be sitting; alternatively, male may be supine for first part of examination and stand for hernia checkIt is normal for a male to feel apprehensive about having his genitalia examined, especially by a female examinerYounger adolescents usually have more anxiety than older adolescentsBut any male may have difficulty dissociating a necessary, matter-of-fact step in physical examination from feeling this is an invasion of his privacyObjective DataAdolescentAdolescents show wide variation in normal development of genitalsUsing SMR charts, note:Enlargement of testes and scrotumPubic hair growthDarkening of scrotal colorRoughening of scrotal skinIncrease in penis length and widthAxillary hair growthBe familiar with normal sequence of growthObjective Data:Developmental CompetenceInfant or toddler (cont.)Inspect penis and scrotum (cont.)Migratory testes, physiologic cryptorchidism, is common because of strength of cremasteric reflex and small mass of prepubertal testesNote that affected side has normally developed scrotum; these testes descend at puberty and are normalWith true cryptorchidism, the scrotum is atrophicPalpate epididymis and spermatic cord as described in adult sectionObjective Data:Developmental CompetenceInfant or toddler (cont.)Inspect penis and scrotum (cont.)If uncircumcised, foreskin normally tight during first 3 months and should not be retracted because of risk of tearing membrane attaching foreskin to shaftThis leads to scarring and possibly to adhesions later in life In infants older than 3 months of age, retract foreskin gently to check glans and meatus; it should return to its original position easilyScrotum looks pink in white infants and dark brown in dark-skinned infantsRugae well formed in full-term infantObjective Data:Developmental CompetenceInfant or toddlerPerform this procedure right after abdominal examinationIn preschool-age to young school-age child, 3 to 8 years of age, leave underpants on until just before examinationIn an older school-age child or adolescent, offer an extra drape, as with adult; reassure child and parents of normal findingsObjective Data:Developmental CompetenceTake time to consider these feelings, as well as to explore your ownYou may feel embarrassed and apprehensive tooYou may worry about your age, lack of clinical experience, causing pain, or even that your movements might “cause” an erectionSome examiners feel guilty when this occurs; you need to accept these feelings and work through them so that you can examine the male in a professional wayDiscuss these concerns with an experienced examinerYour demeanor is important; your unresolved discomfort magnifies any discomfort the man may haveObjective DataAdditional history for aging manAny difficulty urinating?Have you experienced any hesitancy or straining, a weakened force of stream, dribbling, or incomplete emptying?Do you ever leak water or urine when you don’t want to? Do you use pads/tissue to catch urine in your underwear?Do you need to get up at night to urinate?What medications are you taking? What fluids do you drink in the evening?Subjective DataAdditional history for preadolescents and adolescents (cont.)Has anyone ever touched your genitals and you did not want them to?Another boy, or an adult, even a relative?Sometimes that happens to teenagersYou should remember it is not your fault and you should tell another adult about itSubjective DataAdditional history for preadolescents and adolescents (cont.)Often boys your age have questions about sexual activityWhat questions do you have? How about things like birth control, or STIs such as gonorrhea or herpes? Do you have any questions about these?Are you dating? Someone steady? Have you had intercourse? Are you using birth control?What kind of birth control do you use?Has a nurse or doctor ever taught you how to examine your own testicles to make sure they are healthy?Subjective DataAdditional history for preadolescents and adolescents (cont.)Boys around age 12 to 13 have normal experience of fluid coming out of penis at night, called nocturnal emissions, or “wet dreams” Have you had this?Teenage boys wonder if they are only ones who ever had them, like having an erection at embarrassing times, having sexual fantasies, or masturbatingBoys might have thoughts about touching another boy’s genitals and wonder if he might be homosexualWould you like to talk about any of these things?Subjective DataAdditional history for preadolescents and adolescents (cont.)Around age 12 to 13, but sometimes earlier, boys start to change and grow around penis and scrotum; what changes have you noticed?Have you ever seen charts and pictures of normal growth patterns for boys? Let’s go over these now.Who can you talk to about your body changes and about sex information? How do these talks go? What about sex education classes at school? How about your parents? Is there a favorite teacher, nurse, doctor, minister, or counselor to whom you can talk?Subjective DataAdditional history for preadolescents and adolescents (cont.)Start with a permission statement: “Often boys your age experience... ” This conveys that it is normal and all right to think or feel a certain wayTry the ubiquity approach, “When did you . . . ” rather than “Do you . . . ” This method is less threatening because it implies that topic is normal and unexceptionalDo not be concerned if a boy will not discuss sexuality with you or respond to offers for informationYou do well to “open the door;” adolescents may come back at a future timeSubjective DataAdditional history for infants and children (cont.)Ask directly to preschooler or young school-age child: Has anyone ever touched your penis or in between your legs and you did not want them to? Tell him that sometimes that happens to children and it’s not okay They should remember that they have not been badThey should try to tell a big person about itCan you tell me three different big people you trust who you could talk to?Subjective DataAdditional history for infants and children (cont.)Any problem with child’s penis or scrotum, such as sores, swelling, or discoloration?Have you been told if his testes are descended?Has he ever had a hernia or hydrocele?Does he have any swelling in his scrotum during crying or coughing?Subjective DataAdditional history for infants and childrenDoes your child have any problem urinating? Does his urine stream look straight?Any pain with urinating, crying, or holding the genitals?Any urinary tract infections?If child older than 2 to 2½ years of ageHas toilet training started? How is it progressing?If child is 5 years old or older, does he wet bed at night? Is this a problem for child or for parents? What have you done? How does the child feel about it?Subjective DataSTI contactAny sexual contact with a partner having an STI, such as gonorrhea, herpes, AIDS, chlamydia, venereal warts, or syphilis?When was this contact? Did you get the disease?How was it treated? Were there any complications?Do you use condoms to help prevent STIs?Do you have any questions or concerns about any of these diseases?Subjective DataSexual activity and contraceptive useAre you in a relationship involving sexual intercourse?At times, phrase your questions so that all is right for person to acknowledge a problemHow many sexual partners have you had in the last 6 months?What is your sexual preference? Do you prefer a relationship with a woman, a man, or both?Subjective DataSexual activity and contraceptive useAre you in a relationship involving sexual intercourse?Are aspects of sex satisfactory to you and your partner?Are you satisfied with the way you and your partner communicate about sex?Occasionally a man notices a change in ability to have an erection when aroused. Have you noticed any changes?Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about this method?Subjective DataPenisHave you had any problem with your penis, such as pain or lesions?Any discharge? How much? Increased or decreased since start? Color? Odor? Discharge associated with pain or urination?Scrotum, self-care behaviorsAny problem with scrotum or testicles?Any lumps or swelling on testes? Change in size of scrotum? History of undescended testicle as infant? Any bulge or swelling in scrotum?Have you ever been told you have a hernia? Have you had any dragging, heavy feeling in scrotum?Subjective DataGenitourinary historyHave you had any difficulty controlling your urine?True incontinence: loss of urine without warningUrgency incontinence: sudden loss, as in acute cystitisDo you accidentally urinate when you sneeze, laugh, cough, or bear down?Do you have any history of kidney disease, kidney stones, flank pain, urinary tract infections, or prostate trouble?Subjective DataHesitancy and strainingDo you have any trouble starting urine stream?Do you need to strain to start or maintain stream?Has there been any change in force of stream?Have you experienced dribbling, so that you must stand closer to toilet?Afterward, do you still feel you need to urinate?Have you ever had any urinary tract infections?Urine colorIs usual urine clear or discolored, cloudy, foul-smelling, or bloody?Subjective DataFrequency, urgency, and nocturia Are you urinating more often than usual?Do you feel as if you cannot wait to urinate?Do you awaken during the night because you need to urinate? How often? Is this a recent change?Nocturia occurs with frequency and urgency in urinary tract disorders; other origins include cardiovascular, habitual, diuretic medicationDysuriaAny pain or burning with urinating?Burning common with acute cystitis, prostatitis, and urethritisSubjective DataAdditional history for preadolescents and adolescents (cont.)Use the following questions regarding sexual growth and development and sexual behaviorFirst ask questions that seem appropriate for boy’s age, but be aware that norms vary widelyWhen you are in doubt, it is better to ask too many questions than to omit somethingChildren obtain information, often misinformation, from media, internet, and from peers at surprisingly early agesAsk direct, matter-of-fact questions; avoid sounding judgmentalSubjective DataAdditional history for aging man (cont.)A man in his 70s, 80s, or 90s may notice changes in his sexual relationship or in his sexual response and wonder if it is normalFor example, it is normal for an erection to develop slowly at this ageThis is not sign of impotence, but a man might wonder if it isSubjective DataCircumcision (cont.)Circumcision lowers risk of certain STIs, specifically syphilis, chancroid, and somewhat reduced risk of genital herpesCircumcised men have a significantly lowered risk of acquiring genital HPV infection, and their partners have a lower risk of cervical cancerFinally, epidemiological studies now suggest a potential reduction in acquisition of HIV in circumcised menStructure and Function:Cultural Competence (cont.)CircumcisionDuring pregnancy or immediate neonatal period, parents may ask whether or not to circumcise male infantThere are religious and cultural indications for circumcision, also prevention of phimosis and inflammation of glans penis and foreskin, decreasing incidence of cancer of penis, and slightly decreasing incidence of urinary tract infections in infancyStructure and Function:Cultural CompetenceSexual expression in later lifeChronologic age by itself should not mean a halt in sexual activity; physical changes need not interfere with libido and sexual pleasureOlder male is capable of sexual function as long as he is in reasonably good health and has an interested, willing partnerDanger is in male misinterpreting normal age changes as a sexual failure; once this idea occurs, it may demoralize man and place undue emphasis on performance rather than on pleasureStructure and Function: Developmental CompetenceAdult and aging men (cont.)Testosterone production declines after age 55 to 60 yearsDecline proceeds graduallyAging changes also are due to decreased muscle tone, subcutaneous fat, and cellular metabolismPubic hair decreases and penis size decreasesDue to decreased tone of dartos muscle, scrotal contents hang lower, rugae decrease, and scrotum becomes pendulousTestes decrease in size and are less firm to palpationIncreased connective tissue is present in tubules, so these become thickened and produce less spermStructure and Function: Developmental CompetenceAdult and aging menMale does not experience a definite end to fertility as female doesAround age 40 years, production of sperm begins to decrease, although it continues into 80s and 90sAfter age 55 to 60 years, testosterone production declinesStructure and Function: Developmental CompetenceAdolescentsPuberty begins between ages of 9½ and 13½First sign is enlargement of testesNext, pubic hair appears, then penis size increasesStages of development are documented in Tanner’s sexual maturity ratingsComplete change in development from preadolescent to adult takes around 3 years, although normal range is 2 to 5 yearsStructure and Function: Developmental CompetenceInfantsPrenatally, testes develop in abdominal cavity near kidneysDuring later months of gestation testes migrate, pushing abdominal wall in front of them and dragging the vas deferens, blood vessels, and nerves behindDescend along inguinal canal into scrotum before birthAt birth, testis measure 1.5 to 2 cm long and 1 cm wideOnly a slight increase in size occurs during prepubertal yearsStructure and Function: Developmental CompetenceLoss of spouseDepressionPreoccupation with workMarital or family conflictSide effects of medicationsHeavy use of alcoholLack of privacy, living with adult children or in a nursing homeEconomic or emotional stressPoor nutrition or fatigueSexual expression in later life (cont.)In the absence of disease, withdrawal from sexual activity may be due to:Structure and Function: Developmental Competence

Are you urinating more often than usual?Do you feel as if you cannot wait to urinate?Do you awaken during the night because you need to urinate? How often? Is this a recent change?Nocturia occurs with frequency and urgency in urinary tract disorders; other origins include cardiovascular, habitual, diuretic medicationDysuriaAny pain or burning with urinating?Burning common with acute cystitis, prostatitis, and urethritisFrequency, Urgency, NocturiaSubjective Data